The Impact of Constraint-Induced Movement Therapy on Motor Recovery in Middle Cerebral Artery Infarction Having Cardiomegaly in an Intensive Care Unit

Stroke can be characterized by rapidly emerging neurological manifestations of global or focal impairment of neurological functionality, with consequences lasting a day or more or giving rise to mortality, with no significant etiology other than vascular origin. A middle cerebral artery (MCA) infarct is a form of stroke that develops when the MCA, one of the primary arteries providing blood to the brain, becomes blocked or obstructed. Constraint-induced movement therapy (CIMT) is an emerging method that has mainly been utilized to rehabilitate stroke patients, especially upper extremities. According to recent advances, CIMT can also be applied to the lower limbs to increase insufficient limb balance, thereby facilitating gait. This case report is based on a 65-year-old female who had weakness in the left side of the body and slurring of speech and was diagnosed with an MCA infarct. She was managed with CIMT in the ICU along with conventional physiotherapy. The outcomes showed that CIMT is a beneficial approach for patients with stroke.


Introduction
Strokes are the world's second-ranked significant factor for death and the third-ranked significant form of disability [1].A stroke is described by the WHO as a suddenly evolving cerebral presentation of a worldwide or local impairment of function in the brain, with repercussions lasting longer than 24 hours or leading to mortality, with no significant etiology beyond its vascular origin [2].Strokes are divided into two types: ischemic (80-87%) and hemorrhagic (13-20%).Ischemic strokes are the result of thrombus, embolism, or widespread hypoperfusion [3].Cerebrovascular accident is an epidemic issue that is the leading parameter of disability in people [4].According to the most recent data, 16.9 million individuals experience a cerebrovascular accident each year, with a worldwide incidence of 258 per 100,000 people per year, considerable discrepancies between high-and low-income countries, and an age-adjusted epidemiology 1.5 times higher in men than in women [5].The epidemiology of cerebrovascular accidents in low-and middleincome nations has more than quadrupled during the last four decades [6].
Ischemic strokes are categorized into three types: anterior cerebral artery, middle cerebral artery (MCA), and posterior cerebral artery.MCA infarcts are the most common and impact motor activity due to their involvement in the corticospinal tract [7].When blood flow from the MCA, one of the major arteries in the brain, is unexpectedly halted (ischemia) or completely stopped (infarction), a stroke ensues [8].MCA infarctions can induce symptoms such as rapid-onset paralysis or numbness on one side of the body; typically, the face, arm, or leg are impacted [9].These symptoms can also cause linguistic difficulties, including difficulty speaking.Patients may also experience visual problems, such as hemianopia.Cognitive skills may be affected, resulting in disorientation or confusion [10].Aging, ethnicity, racial or ethnic background, and ancestry are all irreversible predisposing parameters for stroke [11].Among other infectious agents, bacterial pathogens are the most prevalent cause of stroke [12].Flexible stroke risk factors include elevated blood pressure, atrial fibrillation, various cardiac problems, hyperlipidemia, diabetes, smoking, lack of exercise, carotid stenosis, and transient ischemic attack [13].
Constraint-induced movement therapy (CIMT) was invented to address upper extremity limitations following a cerebrovascular accident and is a widely researched strategy for patient physiotherapy.However, recent advances suggest that CIMT also applies to the lower limbs for balance and gait.The original CIMT comprises non-paralyzed arm constraints and task-specific training.Modified types also use non-paralyzed arm restricting, although not as intensely as the primary CIMT.Both original and adapted CIMT positively affected motor activity, arm-hand functions, and self-experienced arm-hand activities in daily life [14].It is anticipated that individuals who can benefit significantly from CIMT account for at least 50% of the overall stroke population [15].Although meant to improve upper arm function, numerous authors have found that it improves balance [16].CIMT, a stroke rehabilitation strategy, necessitates rigorous training of the damaged arm while restricting the mobility of the unaffected arm for six hours daily, five days a week, for two weeks [17].The technique uses behavioral psychology, motor learning, and skill development concepts [18].

Case Presentation Patient information
The patient was a 65-year-old female who was brought to the neuro-outpatient department for complaints of weakness in the left side of the body and slurring of speech.She experienced these complaints for one day.She reported similar complaints six months ago and thereby visited the local hospital, where she was treated with medications.After a month, she experienced weakness on the left side of her body and was again treated with medications.She was admitted to the neurology ward, where specific investigations were done, such as an ECG, a two-dimensional echocardiogram, a color Doppler, an MRI, a complete blood count, a CT scan, and a chest X-ray.The patient had a known case of rheumatic heart disease, mild mitral stenosis, and mitral regurgitation; had a history of bronchial asthma and hypertension for three years; and was on medication for the same.The patient had no history of giddiness or falls.Moreover, there is no record of a head injury, fever, seizures, loss of consciousness, or headache in her medical history.She was then shifted to the medicine intensive care unit (MICU) for four days, then moved to the ward and treated with medications given, including a tablet of Clopitab-A 150 mg, a tablet of Rosuvas 40 mg, and an injection of Optineuron intravenous.

Clinical findings
The patient was endomorphic and had normal vital signs.Notably, both the upper and lower limbs exhibited dry and scaly skin.Notable clinical findings suggested an altered mental state, as the patient was conscious but not oriented to her surroundings.Additionally, the presence of slurred speech raised concerns about potential neurological involvement.The Glasgow Coma Scale score was 13 (E4V4M5), indicating a moderate level of consciousness.Furthermore, the assessment of cardiac function revealed a low ejection fraction, emphasizing the need for a thorough investigation into the neurological and cardiovascular aspects of the patient's condition.Color Doppler imaging indicated atherosclerotic changes in the bilateral common carotid and internal and external carotid arteries.MRI findings showed altered signal intensity in the right corona radiata, lentiform nucleus, and temporal region, along with age-related atrophy and small vessel ischemic disease on the left side.A CT scan of the brain revealed a lesion in the right corona radiata, as shown in Figure 1, and chronic lacunar infarcts in the left gangliocapsular regions, as shown in Figure 2. Chest X-ray supine revealed cardiomegaly, as shown in Figure 3. Neurological assessments showed exaggerated biceps jerk, absent knee jerk, and extensor plantar response on the left side, while reflexes were normal on the right.The tone was 2+ on the right side and 3+ on the left.The patient also exhibited Wernicke's aphasia, adding to the complex clinical picture.

FIGURE 1: CT scan of the brain
The red arrow shows an infarct in the right corona radiata.

FIGURE 3: Chest X-ray eliciting cardiomegaly
The red arrow shows cardiomegaly.

Therapeutic intervention
Along with conventional therapy, CIMT was planned for the patient, which encompasses restricting the non-paralyzed arm and using the paralyzed arm for task-oriented activities.CIMT, constraint-induced movement therapy

Outcome measures
The outcomes of the intervention are shown in Table 4.

Discussion
In 1999, Miltner et al. conducted a clinical trial on CIMT in which the participants were 15 individuals.Nine people had a right-side stroke, and six had a left-side stroke; all were right-arm predominant prior to the stroke.The treatment consisted of two primary parameters using a resting hand splint for 90% duration.At the same time, the patient is awake for the whole span of 12 days for constriction of the movement of the non-impacted upper arm and training of the arm that was impacted through an action known as "shaping" for about seven hours per day on the eight weekdays during that time.Patients improved considerably from before to after therapy on a clinical motor examination and a test evaluating the extent of use of the diagnosed limb in day-to-day activities, with no regression in performance at the six-month follow-up [19].
In 2006, Wolf et al. conducted a randomized controlled trial in which respondents were allocated at random to CIMT, which involved using a hindering mitt on the less affected grasp while practicing and shaping behavior with the hemiplegic hand or conventional therapy, which included no post-rehabilitation treatment to pharmaceutical or physiotherapeutic interventions.Sex and pre-stroke dominance were used to stratify patients.Their findings showed that CIMT resulted in a statistically considerable and medically relevant increase in the quality of arm movements for people who had cerebrovascular accidents during the preceding three to nine months and had it for at least a year [17].The study indicated that LE-CIMT is a valuable management strategy for increasing perceptions of improvements and encouraging paralyzed lower extremities in daily mobility tasks [20].

Conclusions
According to studies, CIMT is the use of the paretic limbs by restricting non-paretic limbs and is mainly used for the upper limbs.Still, recent advances have proved that the therapy can be applicable for lower limbs to maintain balance and facilitate gait.Patients with stroke usually have difficulty performing activities of daily living due to weakness in their paretic limbs; hence, the therapy, which encompasses the use of paretic limbs, was found to be effective.Moreover, the subjective satisfactory experience with the CIMT provides valuable insights into the efficiency of this therapy in patients undergoing cerebrovascular accidents.The promising outcome measures have proved that CIMT in the ICU is a precise and versatile therapy for patients with stroke.Hence, we conclude that CIMT, in addition to primary rehabilitation, has been proven to be a promising approach for the rehabilitation of patients with stroke.

FIGURE 2 :
FIGURE 2: CT scan of the brainThe red circle indicates chronic lacunar infarcts in the left gangliocapsular regions.

FIGURE 4 :
FIGURE 4: CIMT for the left upper limb (A) Bead exercises.(B) The red circle indicates squeezing a ball.CIMT, constraint-induced movement therapy

FIGURE 5 :
FIGURE 5: CIMT progressive exercises for the left upper limb (A) Pegboard exercises.(B) Opening and closing of zips in a zigzag pattern.CIMT, constraint-induced movement therapy

FIGURE 6 :
FIGURE 6: CIMT for the left lower limb (A) The red circle indicates bead exercises.(B) The red circle indicates pegboard exercises.
Choi et al. arranged a randomized controlled experiment in 2017 to evaluate if game-based CIMT improves equilibrium skills in people with cerebrovascular accidents.Thirty-six chronic stroke victims were randomly assigned to one of the following three categories: game-based CIMT (n = 12), general game-based training (n = 12), and traditional (n = 12).For four weeks, all techniques were carried out three times a week.The static balance control and weight-bearing symmetry were examined, as well as the Functional Reach Test (FRT), modified FRT, and Timed Up and Go Tests, to assess balancing abilities.According to the findings, while conventional game-based retraining and game-based CIMT enhanced static and dynamic equilibrium skills, game-based CIMT improved static equilibrium control, weight-bearing symmetry, and side-to-side weight shift to a greater extent[16].Duarte Pereira et al. conducted a multiple case study in 2022, including a convenience sample of 12 participants (eight males) with an average age of 55 years old.The lower extremity CIMT (LE-CIMT) intervention process, combining task-oriented training, motor learning techniques, and a transfer package, was conducted in a clinical environment.CIMT increased gait metrics, reduced test execution time, and enhanced functional mobility in stroke patients, according to the findings.

Table 1
represents the conventional therapy given to the patient; Table2describes the CIMT given for the left upper limb; and Table3describes the CIMT given for the left lower limb.Figures4, 5, 6 show the patient being rehabilitated.2024 Nainani et al.Cureus 16(2): e54384.DOI 10.7759/cureus.543845 of 11

TABLE 1 : Conventional physiotherapy protocol utilized for recovery
ADL, activities of daily living; AROM, active range of motion; PROM, passive range of motion

TABLE 3 : CIMT for lower limbs
CIMT, constraint-induced movement therapy

TABLE 4 : Outcomes of interventions utilized for evaluation post-rehabilitation
BBS, Berg Balance Scale; DGI, Dynamic Gait Index; FIM, Functional Independence Measure; STREAM, Stroke Rehabilitation Assessment of Movement